Sensory Integration Therapy and Auditory Integration Therapy


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Protocol

Sensory Integration Therapy and Auditory Integration Therapy

Medical Benefit Preauthorization

(80313)

Effective Date: 04/01/16

Next Review Date: 07/22

No Review Dates: 04/07, 05/08, 05/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15,

01/16, 01/17, 01/18, 01/19, 01/20, 01/21, 07/21

This protocol considers this test or procedure investigational. If the physician feels this service is medically necessary, preauthorization is recommended.
The following protocol contains medical necessity criteria that apply for this service. The criteria are also applicable to services provided in the local Medicare Advantage operating area for those members, unless separate Medicare Advantage criteria are indicated. If the criteria are not met, reimbursement will be denied and the patient cannot be billed. Please note that payment for covered services is subject to eligibility and the limitations noted in the patient’s contract at the time the services are rendered.

RELATED PROTOCOL Cognitive Rehabilitation

Populations
Individuals: • With developmental
disorders Individuals: • With developmental
disorders

Interventions
Interventions of interest are: • Sensory integration
therapy Interventions of interest are: • Auditory integration
therapy

Comparators Comparators of interest are: • Standard care
Comparators of interest are: • Standard care

Outcomes
Relevant outcomes include: • Functional outcomes • Quality of life Relevant outcomes include: • Functional outcomes • Quality of life

DESCRIPTION Sensory integration therapy has been proposed as a treatment of developmental disorders in patients with established dysfunction of sensory processing, particularly autism spectrum disorder. Sensory integration therapy may be offered by occupational and physical therapists who are certified in sensory integration therapy. Auditory integration therapy uses gradual exposure to certain types of sounds to improve communication in a variety of developmental disorders, particularly autism.
SUMMARY OF EVIDENCE For individuals who have developmental disorders who receive sensory integration therapy, the evidence includes systematic reviews of randomized controlled trials (RCTs) and case series. Relevant outcomes are functional outcomes and quality of life. Due to the individualized approach to sensory integration therapy and the large variations in patients’ disorders, large multicenter RCTs are needed to evaluate the efficacy of this intervention. The most direct evidence on sensory integration therapy outcomes derives from several RCTs. Although some of these trials demonstrated improvements for subsets of outcomes measured, they had small sample
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Protocol

Sensory Integration Therapy and Auditory Integration Therapy Last Review Date: 07/21

sizes, heterogeneous patient populations, and variable outcome measures. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have developmental disorders who receive auditory integration therapy, the evidence includes systematic reviews of RCTs. Relevant outcomes are functional outcomes and quality of life. For auditory integration therapy, the largest body of literature relates to its use in autism spectrum disorder. Several systematic reviews of auditory integration therapy in the treatment of autism have found limited evidence to support its use. No comparative studies identified evaluated use of auditory integration therapy for other conditions. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

POLICY Sensory integration therapy and auditory integration therapy are considered investigational.

MEDICARE ADVANTAGE
Sensory integration therapy may be medically necessary for persons with acquired sensory problems resulting from head trauma, illness or acute neurologic events including cerebrovascular accidents.
Sensory integration therapy is not medically necessary for patients with progressive neurological conditions without potential for functional adaptation.

BACKGROUND
The goal of sensory integration therapy is to improve how the brain processes and adapts to sensory information, as opposed to teaching specific skills. Therapy usually involves activities that provide vestibular, proprioceptive, and tactile stimuli, which are selected to match specific sensory processing deficits of the child. For example, swings are commonly used to incorporate vestibular input, while trapeze bars and large foam pillows or mats may be used to stimulate somatosensory pathways of proprioception and deep touch. Tactile reception may be addressed through a variety of activities and surface textures involving light touch.
Auditory integration therapy (also known as auditory integration training, auditory enhancement training, audiopsycho-phonology) involves having individuals listen to music modified to remove frequencies to which they are hypersensitive, with the goal of gradually increasing exposure to sensitive frequencies. Although several methods of auditory integration therapy have been developed, the most widely described is the Berard method, which involves two half-hour sessions per day separated by at least three hours, over 10 consecutive days, during which patients listen to recordings. Auditory integration therapy has been proposed for individuals with a range of developmental and behavioral disorders, including learning disabilities, autism spectrum disorder, pervasive developmental disorder, and attention-deficit/hyperactivity disorder. Other methods include the Tomatis method, which involves listening to electronically modified music and speech, and Samonas Sound Therapy, which involves listening to filtered music, voices, and nature sounds.1

REGULATORY STATUS Sensory integration therapy is a procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration. No devices designed to provide auditory integration therapy have been cleared for marketing by the FDA.
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Protocol

Sensory Integration Therapy and Auditory Integration Therapy Last Review Date: 07/21

Services that are the subject of a clinical trial do not meet our Technology Assessment and Medically Necessary Services Protocol criteria and are considered investigational. For explanation of experimental and investigational, please refer to the Technology Assessment and Medically Necessary Services Protocol.
It is expected that only appropriate and medically necessary services will be rendered. We reserve the right to conduct prepayment and postpayment reviews to assess the medical appropriateness of the above-referenced procedures. Some of this protocol may not pertain to the patients you provide care to, as it may relate to products that are not available in your geographic area.
REFERENCES
We are not responsible for the continuing viability of web site addresses that may be listed in any references below.
1. Sinha Y, Silove N, Hayen A, et al. Auditory integration training and other sound therapies for autism spectrum disorders (ASD). Cochrane Database Syst Rev. Dec 07 2011;(12):CD003681. PMID 22161380
2. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Sensory integration therapy. TEC Assessment. 1999;Volume 14:Tab 22.
3. Schaaf RC, Burke JP, Cohn E, et al. State of measurement in occupational therapy using sensory integration. Am J Occup Ther. Sep-Oct 2014;68(5):e149-53. PMID 25184475
4. Mailloux Z, May-Benson TA, Summers CA, et al. Goal attainment scaling as a measure of meaningful outcomes for children with sensory integration disorders. Am J Occup Ther. Mar-Apr 2007;61(2):254-9. PMID 17436848
5. Parham LD, Cohn ES, Spitzer S, et al. Fidelity in sensory integration intervention research. Am J Occup Ther. Mar-Apr 2007;61(2):216-27. PMID 17436844
6. Weitlauf AS, Sathe N, McPheeters ML, et al. Interventions Targeting Sensory Challenges in Autism Spectrum Disorder: A Systematic Review. Pediatrics. Jun 2017;139(6). PMID 28562287
7. Case-Smith J, Weaver LL, Fristad MA. A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism. Feb 2015;19(2):133-48. PMID 24477447
8. Brondino N, Fusar-Poli L, Rocchetti M, et al. Complementary and Alternative Therapies for Autism Spectrum Disorder. Evid Based Complement Alternat Med. 2015;2015:258589. PMID 26064157
9. Watling R, Hauer S. Effectiveness of Ayres Sensory Integration(R) and Sensory-Based Interventions for People With Autism Spectrum Disorder: A Systematic Review. Am J Occup Ther. Sep-Oct 2015;69(5): 6905180030p1-12. PMID 26356655
10. May-Benson TA, Koomar JA. Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. Am J Occup Ther. May-Jun 2010;64(3):403-14. PMID 20608272
11. Corbett BA, Shickman K, Ferrer E. Brief report: the effects of Tomatis sound therapy on language in children with autism. J Autism Dev Disord. Mar 2008;38(3):562-6. PMID 17610057
12. Mudford OC, Cross BA, Breen S, et al. Auditory integration training for children with autism: no behavioral benefits detected. Am J Ment Retard. Mar 2000;105(2):118-29. PMID 10755175
13. Porges SW, Bazhenova OV, Bal E, et al. Reducing auditory hypersensitivities in autistic spectrum disorder: preliminary findings evaluating the listening project protocol. Front Pediatr. 2014;2:80. PMID 25136545
14. Zimmer M, Desch L, Rosen LD, et al. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics. Jun 2012;129(6):1186-9. PMID 22641765
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Sensory Integration Therapy and Auditory Integration Therapy Last Review Date: 07/21

15. Occupational Therapy for Children and Youth Using Sensory Integration Theory and Methods in SchoolBased Practice. Am J Occup Ther. Nov-Dec 2015; 69 Suppl 3: 6913410040p1-6913410040p20. PMID 26713950
16. Watling R, Koenig KP, Davies PL, et al. Occupational therapy practice guidelines for children and adolescents with challenges in sensory processing and sensory integration. Bethesda, MD: American Occupational Therapy Association Press; 2011.
17. American Speech-Language-Hearing Association, Working Group in AIT. Auditory Integration Training [Technical Report:]. 2004; https://www.asha.org/policy/ps2004-00218/. Accessed February 23, 2021.
18. National Government Services, Inc. (Primary Geographic Jurisdiction 06 & K - Illinois, Minnesota, Wisconsin, Connecticut, New York - Entire State, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631), Revision Effective Date for services performed on or after 01/01/2020.

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Sensory Integration Therapy and Auditory Integration Therapy